Managing
Public Health Threats That Traverse Geopolitical Borders: A Look at the Impact
of SARS

By

Monica
E. Nussbaum

Updated
19 December 2003

“As we look toward a new century, health concerns are
increasingly global in scope.Unexpected
diseases have surfaced due to altered patterns of land use, the adaptability of
disease pathogens, and other factors.With the ease and frequency of international travel, disease outbreaks
in foreign countries can rapidly cross U.S. borders.This includes infectious diseases such as the
Ebola virus, new variants of the AIDS virus, and dengue fever.Pollutants in the atmosphere, water, and food
chain pose equally insidious risks, contributing to a host of chronic disease
and developmental disorders.”[1]

Purpose

This
paper introduces readers to societal issues that must be studied from a
geopolitical perspective and incorporated into state-level policy-making
discussions for the establishment of effective domestic public health policy
and legislation.[2]With the increasing ease of individual travel
for business and pleasure, and the transporting of goods across geopolitical
borders, public health threats can rapidly traverse the globe and cause
detrimental outcomes in multiple locations within human populations, animal populations,
and the environment.This paper briefly
discusses the history of the formation of international discourse on public
health threats, the development of United States
public health policy and law concerning entry into the United States,
and the development of the World Health Organization public health policy and
law.This paper will focus primarily on
the impact of communicable diseases on health from a geopolitical perspective.SARS will be an example illustrating the
importance of public health powers such as the use of quarantine and isolation.[3]

Introduction

States
must develop domestic public health policy by utilizing an international
perspective as guidance for potential threats to human, animal, and
environmental health.The interplay
between human, animal, and environmental health signifies the importance of
ensuring that public health policies and laws are sufficiently broad to provide
for health protection and promotion, including but not limited to human health.

Geopolitical
borders – demarcated lines that separate states – constitute the principal
boundaries of international politics and law.Boundaries remain highly significant for jurisdictional purposes;
however, boundaries are decreasing in importance regarding trade, economics, development,
and global health.[4]With increasing globalization, increasing
interdependencies between states, and increasing travel, existing geopolitical
borders, without additional preventive measures, no longer afford sufficient
protection for the public health of a state’s population – “[g]lobalization of
trade and travel has increased the chances for the spread of infections.”[5]

Communicable
diseases easily cross state lines and will continue to do so with ever
increasing prevalence, which is why proactive measures must be taken to reduce
the spread of public health threats and to counter and control known and future
unknown threats.Consequently, domestic and international barriers impeding public
health, such as the General Agreement on Tariffs and Trade (“GATT”)
ruling that prohibits the use of trade restrictions for enforcement of public
health laws, and those barriers, which also impede the implementation of
effective health policy, must be reduced significantly if not eliminated.[6]The GATT ruling should be revised to allow
restrictions to be imposed that are most likely to effectively contain a public
health threat until that threat is dissipated.The impact of SARS during 2003 signifies how “globalization has
continued to erode the geopolitical boundaries of nation states, facilitating
their permeation by infectious agents from distant places.”[7]

State
governments use health policies as a means of regulating and promoting the
social utility of its available medical knowledge and capital.[8]However, to establish effective public health
policy, a state must look beyond strict economics and incorporate human values
and ethics.Human values are the
mechanisms by which objectives, priorities, and channels are chosen to
establish policy.Human values can be
viewed on an individual level, i.e., how an individual would act; or on a
societal/communal level, i.e., the best interests of the community.Medical care largely focuses on the
individual without requiring analysis of the impact on a community.Public health, by its very definition, must
focus on the community and what is in the best interest of the community as
opposed to the individual; therefore, in the development of public health
policy and legislation, human values must be determined from the societal
level.Ethics bridge health policy and
values by examining the moral turpitude of required decisions and seeking to
resolve conflicts among values.[9]States must balance their focus when
establishing public health priorities for several reasons.First, public health laws can significantly
impair individual freedoms.Second,
finite resources limit the ability of a state to guard against all threats;
consequently, threats must be analyzed according to potential outcomes and
characterized by the feasibility of preventing negative outcomes.For example, a state could vaccinate the
entire population against a specific disease; however, that action would expend
valuable resources which would then no longer be readily available, and that
vaccination might have significant adverse reactions along the human scale,
excluding financial cost, such as death or deformities.In the context of communicable diseases,
diseases that do not present short-term death cannot preside in priority status
over diseases the cause immediate death.[10]However, states must create flexible public
health policies so that programs and resources can be readily adapted with
little notice to reduce the impact that a burgeoning disease may have.

The
primary determinants of health are significant when studying international,
regional, and local patterns of disease.The primary constructs of health include: human biology, environment,
lifestyle, and medical care.[11]Of these, only one construct presents
significant difficulty for management – human biology, i.e., genetics.State policy makers have varying measures of
power to impact the environment, individual lifestyles, and access to and
quality of medical care.By controlling
these factors and thus reducing the risks posed to the public health of a
population, states are able to formulate effective public health policy.However, states must incorporate global
awareness into domestic health policy as “[c]ommunicable diseases present
enormous transnational (and often global) challenges that are beyond the
governance capabilities of individual nation states and require
multilateral/global approaches.”[12]Communicable diseases know no borders, travel
extensively and rapidly, and are relatively indiscriminate in choosing victims.[13]The following table lists many health issues
that should be studied and addressed in the formulation of domestic public
health policy.

Public Health Issues that Can Cause Disparate Impacts Across Geopolitical
Borders

Agriculture

Bioterrorism

Communicable Disease

Drug Trafficking
and Use

Environmental
Degradation

Genetic
Modification:

§Human

§Animal

§Agricultural

Hunger

Individuals
Seeking Political Asylum

Medical Care:
Access, Quality, and Treatment

Migrant Workers

Prostitution

Pollution

Ports of Entry

Poverty (Individual
and State)

Refugees

Terrorism

Tourism

Travel (Public and
Private)

§Airplanes

§Buses

§Cruise Ships

§Subways

§Taxi cabs

§Trains

War

War Victims

Weapons of Mass
Destruction

The
Development of International Discourse on the Globalization of Public Health Threats

“Because
communicable diseases do not respect the geopolitical boundaries of nation
states, and state sovereignty is an alien concept in the microbial world, all
of humanity is now vulnerable to the emerging and re-emerging threats of
communicable diseases.”[14]

“The
‘transnationalization’ of infectious diseases across geopolitical boundaries
during the European cholera epidemics of 1830 and 1847 catalysed the evolution
of the earliest multilateral governance of communicable diseases.”[15]In 1851, France hosted the first
International Sanitary Conference.[16]Eleven European states attended this
conference.During the next five
decades, the international community held ten additional conferences to
primarily discuss the proliferation of cholera, plague, and yellow fever across
borders.[17]Although the negotiated conventions were
never ratified; therefore, not becoming law, the conferences solidified the
importance of addressing the spread of disease across geopolitical borders
within the international community.[18]In 1905, the Inter-American Sanitary
Convention mandated notice requirements for incidence of cholera, plague, and
yellow fever.[19]The Pan-American Sanitary Code, instituted in
1924, furthered this effort by requiring either bi-weekly notification or
immediate notification for a specified list of communicable diseases, and
requiring immediate notification for new contagions likely to traverse
geopolitical borders through international commerce.[20]In 1912, the international community ratified
a treaty to control the use of opium.[21]By the establishment of the World Health
Organization (WHO) in 1948, the list of drugs controlled through international
regulation had grown to at least eighteen.[22]Through organizations such as the WHO, the
United Nations Children’s Fund (UNICEF), the United Nations Population Fund
(UNFPA), the Joint United Nations Programme on HIV/AIDs (UNAIDS), the United
Nations Development Fund (UNDP), United Nations Educational, Scientific and
Cultural Organization (UNESCO), and the World Bank, among others, “the United
Nations system has been in the forefront of the fight against disease through
the creation of policies and systems that address the social dimensions of
health problems.”[23]Today, the WHO “establishes international
standards on biological, pharmaceutical and similar substances.”[24]The WHO has formulated a list of over “306
drugs and vaccines considered essential to help prevent or treat over 80 per
cent of all health problems,” and over 140 states have adapted this list.[25]

Many
states restrict tourists and immigrants infected with specific diseases from
entering their territory.Some states
test all arriving foreign residents for specific diseases while others test
specified groups.For example, the United States
remains the only Western country to either completely bar entry or require
special waivers for entry for foreigners with AIDS.[26]With the emergence of the new and highly
communicable disease SARS in late 2002 and 2003, many states reviewed and
updated their domestic public health laws and policies and their regulations
imposed on persons engaged in travel to and from sites with known SARS cases
whether the travel was domestic or international, including the potential usage
of quarantine and isolation.[27]

The
History of US
Policy and Law: Communicable Disease as a Geopolitical Threat

In the United States,
medically screening immigrants is not a new phenomenon.[28]During the late 19th and early 20th
centuries, individuals infected with specified contagious diseases were prohibited
from entering the United
States.In 1987, Congress prohibited entrance of HIV-infected immigrants and
travelers into the United
States.[29]Through the Fogarty International Center
(FIC), the United States
has provided training for over 1000 scientists and health professionals from
over 80 countries in AIDS prevention.[30]The individuals trained at the FIC’s AIDS
International Training and Research Program constitute important geopolitical
links in the battle against the spread of HIV/AIDS.

The CDC
is one of the primary public health agencies in the United States and is focused on
promoting “health and quality of life by preventing and controlling disease,
injury, and disability.”[31]Today, the CDC includes the Division of
Global Migration and Quarantine to reduce “morbidity and mortality due to
infectious diseases among immigrants, refugees, international travelers and
other mobile populations that cross international borders.”[32]The Division of Global Migration and
Quarantine also focuses on “promoting border health and preventing the
introduction of infectious” diseases into the United States.[33]

Executive
Order 13295, dated April 4, 2003, grants the CDC authority to apprehend or
detain individuals to prevent the introduction, transmission, or spread of the
following specified communicable diseases: “Cholera; Diphtheria; infectious
Tuberculosis; Plague; Smallpox; Yellow Fever; and Viral Hemorrhagic Fevers
(Lassa, Marburg, Ebola, Crimean-Congo, South American, and others not yet
isolated or named.”[34]In addition, the Executive Order added the
newly discovered disease SARS to the list of quarantinable diseases.

Title 42
section 71 of the United States Code regulates foreign quarantine by
specifically regulating those diseases that are quarantinable, reporting
measures for various methods of travel, sanitary inspection requirements upon
arrival at US ports, and how to handle imported goods.Title 42 of the United States Code (42 U.S.C.
§§264-272) specifies the regulations controlling communicable diseases, the
regulations for quarantine, and the applicable penalties for violations.Section A provides for promulgation and
enforcement by the Surgeon General.[35]Section B provides for the apprehension,
detention, or conditional release of individuals.[36]Section D provides for the apprehension and
examination of persons reasonably believed to be infected with a communicable
disease in a communicable stage.[37]

42 U.S.C.
265 regulates “the suspension of entries and imports from designated places to
prevent spread of communicable diseases.”[38]The CDC operates eight fully staffed
quarantine stations in the United
States.In addition, the CDC places quarantine inspectors at United States’
borders and ports of entry to respond to possible illnesses in arriving individuals
and to ensure that appropriate medical steps are taken.[39]

A
Brief History of WHO Policy and Law: Communicable Disease as a Geopolitical
Threat

In 1951,
the World Health Organization created and adopted the International Sanitary
Regulations, which was subsequently modified and renamed as the International
Health Regulations (IHR).[40]The IHR, a legally binding set of
regulations, constitutes “one of the earliest multilateral regulatory
mechanisms strictly focusing on global surveillance for communicable diseases.”[41]The fundamental principle of the IHR is to
keep interference with world traffic at a minimum while ensuring maximum
security against the spread of diseases.[42]The WHO requires member states to report
outbreaks of specified communicable diseases.In addition, during outbreaks of specific diseases, the IHR requires
travelers from infected areas to present health and vaccination certificates.[43]

Compliance
with the WHO IHR appears to be lax as member states are fearful about
consequences, such as trade restrictions, if outbreaks are reported.Consequently, the WHO, through revision, has
focused on “five key areas: global health security (epidemic alert and
response), public health emergencies of international concern, routine
preventive measures, national IHR focal points, and the need for synergy
between the IHR and other related international regimes.”[44]Additionally, international organizations,
not formally associated with healthcare and public health, are beginning to
understand the impact of public health threats across a broad spectrum of
arenas.For example, the World Trade Organization (WTO), an international
organization outside of the health sciences field, adopted the Doha
Declaration, in recognition of “the gravity of the public health problems
afflicting many developing countries, especially HIV/AIDS, tuberculosis,
malaria, and other epidemics.”[45]Additionally, the Declaration on the TRIPS
Agreement and Public Health, adopted on November 14, 2001, outlined seven
issues related to the promotion of public health by the World Trade
Organization, including intellectual property rights for pharmaceuticals and
allowing members to take necessary steps to protect public health.[46]

In 1988,
the WHO established a partnership to combat river blindness in West Africa.This
partnership was more recently was expanded to include thirty endemic countries
in Africa.[47]In addition, the WHO launched the Global
Polio Eradication Initiative in 1988 with the mission of eradicating
transmission of wild poliovirus by the end of 2000.[48]In 1997, the WHO initiated a program to
combat meningitis and rabies.[49]In 1999, the WHO began to target malaria and
tuberculosis.[50]

The Importance of Public Health Protective, Preventive, and
Containment Measures during the SARS Outbreak of 2002 and 2003

Recently, individuals located not only in one geographic
region but also around the world have contracted the relatively new and unknown
disease known as Severe Acute Respiratory Syndrome (SARS).The rapid spread of this highly contagious
disease greatly taxed the public health systems of numerous states.“As bacteria and viruses become resistant to
anti-microbials and new emerging infections appear, it can be expected that
personal restrictions and isolation will again be a core strategy in public
health.”[51]The outcomes of outbreak, which initiated in Asia and rapidly spread to neighboring countries and to
over two dozen countries in four continents, perhaps were not as catastrophic
as could have been because of specific public health measures including the use
of quarantine and isolation.Quarantine
is a public health tool whereby individuals who have been in contact with
infected individuals or localities are prohibited from activities outside a
specified area for a specified time in order to ensure that the individual does
not develop the disease and subsequently spread that disease to others.Isolation is a tool in which infected
individuals are isolated until the likelihood of spreading the disease to
others has subsided.The difference
between quarantine and isolation is that with quarantine the movement of
non-infected persons is restricted, whereas with isolation the movement of
infected persons is restricted.An
individual in quarantine who contracts the disease will be moved to
isolation.Although these protective
measures have been implemented for hundreds of years, these “[p]ersonal
restrictions pose two legal problems: they violate an individual’s right of
autonomy, and they can be an invasion of privacy to the extent that they must
be publicly known.”[52]As of mid-April 2003, 3,200 individuals had
contracted SARS and 154 had died from this disease.SARS did not come to the attention of the
global public health scene until March 2003; however, the first known cases
were identified as early as November 2002.Due to the rapid spread of SARS around the world, the WHO issued its
first-ever travel warning in early April 2003 advising individuals against
traveling to Hong Kong and the Guangdong province unless absolutely essential.[53]Between “November 1, 2002 and May 14, 2002, a
total of 7,628 SARS cases were reported to the WHO from 29 countries” and “587
deaths . . . have been reported.”[54]To understand why quarantine and isolation
are effective public health tools that must be kept in the repertoire of
methods for controlling the spread of disease, it is useful to analyze the
impact of SARS on those states that were most severely impacted: China and Taiwan.Additionally, a look at how the United States
managed the SARS epidemic provides comparative data about the impact of
quarantine and isolation.

China:
Between March and July of 2003, approximately 2,521 probable cases of SARS were
reported.[55]Consequently, an estimated 30,000 Beijing residents were
quarantined in their homes or quarantine sites.Initially, the Chinese Ministry of Health required quarantine to last
for fourteen days for persons who met specified criteria for contact with a
known SARS infected person.The period
was later reduced to ten days and subsequently to three days.[56]Additionally, persons who entered Beijing with fevers
greater than 100.4 degrees Fahrenheit and who arrived from SARS infected
locations were also placed under quarantine.[57]All persons who were placed under quarantine
received daily visits from quarantine officers and were provided with
necessities such as food and medicine.If an individual contracted the disease then he/she was transferred from
home quarantine to a hospital for isolation.[58]The ChineseCenter
for Disease Control and Prevention (China CDC) conducted a survey to determine
the efficacy of quarantine and to guide future policy decisions.Within the Haidian District, 5,186 persons
were quarantined at some point during March 1 through May 23.After May 26, 1,210 residents were sampled
with an eighty-five percent response rate.Of these individuals, 232 acquired probable SARS during their quarantine
period, and only individuals who had a history of contact with a SARS patient
acquired SARS during the quarantine period.[59]This survey is significant because it
illustrates which populations are most likely to contract SARS and, therefore,
should be placed under quarantine.By
“focusing only on persons who had contact with an actively ill SARS patient . .
. the numbers of persons quarantined [would have been reduced] by approximately
66% . . . .”[60]However, it is important to note that the
survey conducted is subject to several limitations, including but not limited
to the following: 1. It is an initial survey.2. The survey was not representative of all persons quarantined.3. It was subject to self-reported data.4. The infection status of the participants
was not based on clinical diagnosis.[61]

Taiwan: In Taiwan, 131,132 persons were placed
under quarantine, of this 50,319 persons had close contacts with SARS patients
and 80,813 were travelers from WHO-designated SARS-affected areas.[62]The quarantine was extensive because
“unrecognized cases of SARS led to nosocomial clusters and subsequent spread,”
which “resulted in substantial morbidity and mortality and resulted in the
closure of several large health-care facilities.”[63]In Taiwan, quarantined persons were
required to take their own temperature several times per day and to seek
immediate medical care if any of the following symptoms were present: cough,
fever, shortness of breath, and other respiratory symptoms.Additionally, Taiwan quarantined persons on two
levels that allowed varying degrees of activity outside of the quarantine
site.However, trips outdoors were
recorded to ease in possible future investigations.[64]As of yet, an analysis of the impact of
quarantine and isolation has not been conducted in Taiwan.

United States: By May 14, 2003, 345 SARS
cases were identified in the United
States and reported from thirty-eight
states.[65]Sixty-four of these cases were classified as
probable SARS which is more serious than suspect SARS.Of these cases, approximately ninety-seven
percent were attributable to international travel within ten days prior to
onset of illness.[66]The United
States, in contrast to China
and Taiwan,
did not incur significant secondary spread and consequently did not utilize
quarantine as a preventive measure; however, infected individuals were
isolated.[67]During the SARS outbreak in the United States,
CDC quarantine officials:

§Provided information about SARS to air travelers
and to persons traveling via cargo and cruise ships who were arriving, directly
or indirectly, from East Asia,

§Distributed over 20,000 health notices advising
travelers that they might have been exposed to SARS and how to monitor their
health,

§Assessed symptoms of individuals on airplanes to
ensure they do not have SARS, and

§Updated government agencies, and state and local
health departments.[68]

Conclusion

“Public
health is no longer the prerogative of physicians and epidemiologists.International health law, which encompasses
human rights, food safety, international trade law, environmental law, war and
weapons, human reproduction, organ transplantation, as well as a wide range of
biological, economic, and sociocultural determinants of health, now constitutes
a core component of global communicable disease architecture.”[69]Specific behaviors and related diseases
disproportionately affect developing countries, which already have fragile
health and social infrastructures.For
example, the increase of injecting drug users in developing countries presents
threats of outbreaks of HIV and hepatitis C.[70]To effectuate scientific solutions for global
health threats, the international community must make a coordinated global
response.Dr. John Evans, Chairman of
the Commission on Health Research for Development, aptly remarks in testimony
before the United States House Appropriations Committee, “that with increased
awareness of global interdependence in health, self-interest should reinforce
humanitarian concerns’ in our efforts to improve global health.”[71]One mechanism by which to achieve improved
global health is to shift public health education from focusing primarily on
research to preparing and enabling providers to implement appropriate public
health practices.[72]However, to effectively combat the spread of
highly communicable diseases, especially those diseases which are new and the
pathology of which is not yet understood or known, it is imperative for states
to inform the international community of local public health problems.The spread of SARS might have remained much
more localized if China,
the first state to see the disease, had informed the WHO and the international community
of the unknown pathogen when the pathogen first appeared.As previously stated, the first case of SARS
was diagnosed in China
in November of 2002; however, the international community did not become aware
of the virus until March of 2003, at which point, the disease had already
spread to many states and infected many persons.Although detrimental economic effects might
befall a state when that state reports an unknown and highly communicable
disease to the international community, the economic effects will most likely
be temporary and the international community will aid in addressing the disease
and preventing further spread, and thus protecting the public health of many
states.“The international spread of
disease underscores the need for strong global public health systems, robust
health service infrastructures, and expertise that can be mobilized quickly
across national boundaries to mirror disease movements.”[73]

[2]Many of the issues discussed are to some
extent reflected upon by international health organizations for the formulation
of international governmental and organizational policies; however, this paper
serves to illustrate the importance of incorporating these issues into the
formulation of domestic public health policy to safeguard against threats and
to ensure a healthy public.

[3]See Gina Kolata, Flu: The Story of the
Great Influenza Pandemic of 1918 and the Search for the Virus That Caused It,
New York:
Touchstone, 2001, for an interesting discussion of the flu pandemic of the
early twentieth century.

[5]Basic Facts About the United Nations.
New York:
United Nations, 1998 (164).

[6]GATT’s restriction has one exception: trade
restrictions can be used to enforce public health law only if the state can
show that the state is using the least trade restrictive policy possible.Breslow, Marc.“How Free Trade Fails: How GATT & NAFTA
harm democracy, ecology, & the Third World.”Dollars and Sense.October 1992: 6-9.SIRS Database.

[13]Infectious diseases largely do not
discriminate between persons; however, individual risk factors, including age,
general health status, and co-infections, do impact both the likelihood that an
individual will acquire a specific disease and the impact of that disease on
the individual.Although the average of
persons with SARS was in the range of thirty to forty years of age, young
children and olders persons, and persons with other health problems were much
more likely to have significantly worse outcomes, including death, brought on
by the SARS virus.

[39]“The SARS Investigation: The Role of CDC’s
Division of Global Migration and Quarantine.”The Centers for Disease Control and Prevention.March 31, 2003.Available at: http:www.cdc.gov.Accessed on: April 13, 2003.

[47]“WHO In Partnership: Examples of Work With The
Public and Private Sectors to Fight Infectious Diseases.”Fact Sheet No 235, October 1999.Available at: http://www.who.int.Accessed on: April 10, 2003.